Health inspection·June 30, 2022

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few not include an assessment completed for the self-administration of medications. The Admission/readmission Data Collection, effective 9/28/20, indicated Resident #19 was alert and oriented to person, place, and time. The data collection identified the resident did not self-administer medications. 3. An observation was made on 6/27/22 at 4:32 p.m. of a Symbicort inhaler lying on top of Resident #12's over-bed table. The table had water marks, remnants of food, and other personal and food items. Resident #12 stated it was her emergency inhaler. The resident stated staff put liquid in the machine (nebulizer) and she takes it off (when finished). (Photographic Evidence Obtained) An observation was made on 6/28/22 at 2:25 p.m. of two Symbicort inhalers lying on top of Resident #12's over-bed table. The table remained to have water marks, remnants of food, and other personal items. Resident #12 was not in the room however the roommate was. (Photographic Evidence Obtained) An observation was made on 6/29/22 at 3:22 p.m. with Staff G, Unit Manager/Registered Nurse (UM/RN) of Resident #12's room. The staff member confirmed the presence of one Symbicort inhaler on the over-bed table. The UM removed the inhaler from the room and confirmed Resident #12 had not been assessed for self-administration of medication. (Photographic Evidence Obtained) A review of Resident #12's Order Summary Report, active as of 6/29/22 at 4:18 p.m., did not include a physician order allowing the resident to self-administer any medication. The Admission/readmission Data Collection, effective 4/12/22, indicated the resident was alert and oriented to person, place, and time. The data collection identified the resident did not self-administer medications. A review of Resident #12's June 2022 Medication Administration Record (MAR) identified the following orders: - Symbicort Aerosol 160-4.5 microgram (mcg)/actuation (act) - 2 puff inhale orally twice daily for respiratory therapy. This order started on 4/12/22 and was discontinued on 6/29/22 at 4:31 p.m., one hour after the observation was made with Staff G of a Symbicort inhaler lying on the resident's over-bed table. - Pending Confirmation Symbicort Aerosol 160-4.5 mcg/act - 2 puff inhale orally twice daily for respiratory therapy. May self-administer. This order was to start on 6/30/22 at 7:00 a.m. The facility provided an Evaluation for Self-Administration of Medications, effective 6/29/22 at 3:58 p.m., (thirty-six minutes after the observation with Staff G) for Resident #12. The evaluation identified the medication to be self-administered was inhaler, and did not identify the actual medication that was to be self-administered. The instructions for the evaluation indicated Medications will be administered by nursing staff until this decision is made by the Care Plan Team. Section II of the evaluation identified the routes of medication to be self-administered was oral, in which inhalant was an available route option and not chosen. On 6/29/22 at 3:25 p.m., Staff G, UM/RN reported residents are assessed for self-administration of medications, then the medications allowed to be administered are put in a locked box with an as needed medication log. Staff G, UM/RN identified one resident was allowed to self-administer medications on the [NAME] Wing (where Residents #408, #19, and #12 resided) and the identified resident was not one of the residents (#408, #19, and #12)observed with medications left at the bedside. An interview was conducted, on 6/29/22 at 4:00 p.m., with the Director of Nursing (DON) and a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 2 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regional Director of Nursing (RDON). The DON identified neither Resident #408, #19, and/or #12 had been assessed for self-administration of medications. The DON identified the same resident Staff G, UM/RN had earlier identified as the only resident in the facility that had been assessed for the self-administration of medications. The DON stated residents were assessed for self-administering of medications, a physician order was needed, the residents had to demonstrate the administration, the Interdisciplinary Team discussed the residents' ability, a care plan was added for self-administration, a lock box was given to the resident to hold the medication, and an as needed log was given to the resident to complete. The policy titled, Residents Self-Administrated Medication Procedure, effective 11/30/14, indicated: To offer every resident a life full of independence and freedom, residents who have the cognitive and physical ability to take their own medications are encouraged to do so. A resident who takes his or her own medications must be evaluated by his or her physician to be certain it is acceptable and safe arrangement. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 3 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. An observation was made of room [ROOM NUMBER],on 6/27/22 at 10:57 a.m., where two residents were residing. The observation identified there was dusty pest droppings along the entire length with dust in the window tracks and along the window frame. On the floor of room [ROOM NUMBER], in the corner behind the second bed was dirt/sand from the baseboard. The Packaged Terminal Air Conditioner (PTAC) unit under the window of room [ROOM NUMBER] had a black bio-growth substance and other substances on the outside vent. The bathroom of room [ROOM NUMBER], the toilet was running continuously, a plunger was observed in the corner under the sink, a water basin was on the floor between the toilet and wall, and dust was hanging from the vent on the room's ceiling. (Photographic Evidence Obtained) An observation was conducted on 6/27/22 at 11:25 a.m. of room [ROOM NUMBER]. The windowsill in the room had crumbs of some substance along the edge and the window had a dried substance on it. (Photographic Evidence Obtained) On 6/27/22 at 1:06 p.m., Staff A, Housekeeping Manager and the Housekeeping District Manager stated resident rooms are cleaned daily including weekends. The District Manager stated that during a tour it was noted the floors on the [NAME] Wing were dirty. He observed the toilet was leaking and continued to run in room [ROOM NUMBER] and stated that housekeeping staff should have reported it. Both the District Manager and Staff A observed the outside of the PTAC unit and Staff A stated maintenance took off the front and cleans the inside and confirmed that housekeepers should be cleaning the outside of the unit, and that it was apparent it had not been done. The Housekeeping Manager stated that staff have one form (at the nursing station) to complete for maintenance. On 6/27/22 at 11:31 a.m., an observation was conducted of resident room [ROOM NUMBER]. The observation indicated an unpackaged 60 milliliter syringe lying on the floor under and behind the bed next to the window. An observation of the windowsill area identified dusty cobwebs on the window, in the window track, and in the corner of the windowsill. An observation was made on 6/27/22 at 11:32 a.m. of resident room [ROOM NUMBER]. The observation identified a black substance attached to the outside of the PTAC units vent and a brown wet-looking substance on and inside the bathrooms trash bin. On 6/27/22 at 11:35 a.m., an observation was conducted in resident room [ROOM NUMBER]. The observation identified the PTAC unit was dirty and dusty. The corner of the room, behind bed that was near the window, indicated pest droppings attached to the wall. (Photographic Evidence Obtained) Resident #58, after lunch on 6/27/22, was observed lying on top of a blue mattress and under a knitted blanket with no sheets or pillowcases on the bed. On 6/28/22 at 2:10 p.m., an observation was made with Staff N, CNA of the first bed inside room [ROOM NUMBER]. The bed had no linen on the bed including pillowcases. The staff member stated the resident in room [ROOM NUMBER] probably got up and there was not enough (linen) to make the bed. The staff member reported they (facility) do run out of linens sometimes. On 6/28/22 at 2:17 p.m. Resident #33 stated, It's crazy. Resident #33 reported a couple of weeks ago at 10:40 a.m. (I'm good with time) the facility did not have any linen on the floor and another (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 4 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some time her CNA came into the room to provide incontinence care at 7:20 a.m. and was not able to since there was no linen on the wing. The resident reported the facility lacks linen very frequent. A review of the medical record revealed Resident #33 was admitted on [DATE]. Review of the Quarterly Comprehensive Assessment completed on 4/21/22, showed the resident's Brief Interview for Mental Status (BIMS) score was 15 out of 15 indicating intact cognition. On 6/28/22 at 2:50 p.m., Staff M, Laundry Aide stated that normally she worked 2:30 - 9:30 p.m., but often worked doubles. She stated the facility called her in at 9:30 a.m. because the Housekeeping Manager (Staff A) had to go the floor. The staff member reported the linen (situation) could be better. Staff M reported that floor staff throw away linens as the laundry aide has received bags of dirty briefs and trash in the laundry bins. So she knows that staff get confused and threw away the linens. Staff M stated that each wing received a max of 40 towels per shift and the 3:00 p.m. -11:00 p.m. shift today was only going to get 30 towels because the 7:00 a.m. - 3:00 p.m. shift kept coming in and taking them. 2. During a tour of the East Wing on 06/27/22 at 10:20 a.m., room [ROOM NUMBER] was observed with towels on the floor collecting water that was dripping from the air conditioning (A/C) unit. An interview was conducted with both residents residing in that room. The residents stated the issue has been on-going and the unit has not functioned properly for a period of three months. An interview was conducted on 06/27/22 at11:30 a.m. with Staff K, Housekeeping Aide. Staff K was observed cleaning room [ROOM NUMBER]. Staff K confirmed the A/C has been leaking for quite some time and the Director of Maintenance is aware. Staff K stated he does not change the wet towels on the floor. Staff K said he thought it had been a month or so. An interview was conducted on 06/27/22 at 12:40 p.m. with Staff Q, Certified Nursing Assistant (CNA). Staff Q stated the A/C has not been working for three months. Staff Q stated, It has been leaking, they put towels on the floor all the time. Staff Q stated she had not heard anything about its repairs or why it is leaking. Staff Q stated she works often with the residents in room [ROOM NUMBER] and they had not asked her to turn it down. On 06/27/22 at 2:55 p.m., an interview was conducted with Staff R, CNA. Staff R confirmed the A/C has been leaking for quite some time. Staff R said, I have seen the towels on the floor. They are there because the A/C is leaking. Staff R did not know exactly how long this had been going. An interview was conducted on 06/27/22 at 3:07 p.m. with Staff L, Registered Nurse (RN)/Unit Manager. Staff L stated the A/C has had a problem for a while, about 2- 3 months. Staff R does not know what they are doing to fix it. Staff R stated he had reported it to the DOM. A follow -up interview was conducted on 06/27/22 at 3:22 p.m. with the NHA. The NHA stated the unit has had problems since April or May. The NHA stated a replacement unit was ordered and that it was on back order. The NHA stated they are waiting on a replacement. The NHA stated he offered the residents to move to a different room, but they have refused to move. On 06/27/22 at 3:26 p.m. an interview was conducted with Resident #40, Resident #40 stated to the NHA, You never offered us to move out of the room. We could have moved. Resident #40 stated the only request they made was to be moved together. Resident #40 stated they have been roommates for a while and did not want to be separated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 5 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 06/27/22 at 4:15 p.m., an interview was conducted with the DOM. The DOM stated he had installed a new A/C unit in March. The DOM stated the unit was working fine but early May he was notified it was leaking. The DOM stated he thought it was leaking because the residents were setting the unit below 64 degrees causing it to freeze and, hence leaking. The DOM stated he had educated the residents. When asked how residents who cannot get out of bed without staff assistance would have adjusted the unit, the DOM stated maybe staff do it for them. In a follow- up interview with the NHA on 06/27/22 at 4:25 p.m., the NHA stated the problem was the residents were asking staff to turn the A/C below what is required and the staff were honoring the residents' request. The NHA stated they had educated the residents and the staff not to lower the A/C below 64 degrees. The NHA stated the residents were okay. An immediate tour of room [ROOM NUMBER] was conducted with the NHA. Observation was made of dirty, wet towels on the floor and water under the resident's bed. The NHA agreed it was not an acceptable standard of living. During subsequent tours on 06/28/22 at 12:46 p.m., and 06/29/22 at 12:36 p.m. observations revealed room [ROOM NUMBER] was noted with a water on the floor by window bed and under the resident's bed and the A/C units in Rooms #108, #110 and #114 were observed with bio growth, debris and dust build up. On 06/30/22 at 1:24 p.m., observations were made of room [ROOM NUMBER] with water all over the floor and A/C leaking under the resident's bed. The A/C units with bio growth were observed in Rooms #108, #110, and #114. On 06/30/22 at 9:45 a.m., an interview was conducted with Staff P, Housekeeping. Staff P stated he cleans the resident rooms, and the expectation is for all rooms to be cleaned daily. Staff P stated sometimes they do not get around to cleaning all the rooms because there are only two housekeeping staff working. Staff P stated it is too much work for just the two, but they make it work. Staff P stated it is hard on the housekeeping staff and residents when the residents do not get their rooms cleaned per their standards. On 06/30/22 at 1:50 p.m., a follow -up tour of room [ROOM NUMBER] was conducted with the NHA. The NHA stated they are trying to fix the A/C problem. Resident #40 stated the unit was still leaking and no one had adjusted it all week. During the tour, a water puddle was noted on the floor. The NHA stated he will address the situation. 3. On 06/29/22 at 11:34 a.m., a tour of the kitchen was conducted. The ceiling vents in the kitchen service areas were noted with bio growth, dust, and debris. A total of five vents were noted. An immediate interview was conducted with the Certified Dietary Manager (CDM). The CDM stated the maintenance department is responsible for cleaning the vents. The CDM said, They should have done it. The Dietary District Manager stated she had notified them. The Dietary Manager stated they should have cleaned them. The CDM stated, Can see how debris could fall on the food. On 06/30/22 at 3:28 p.m. an interview was conducted with the DOM. The DOM stated he was the only maintenance personnel in his department. The DOM stated this was why it is hard to keep up with everything. The DOM reviewed the A/C units that were identified with dirt, dust, and bio-growth during four of four days of survey. The DOM stated, they are not supposed to look like that. The DOM said, That does not look good. It is not good for the residents. The DOM stated about a month ago they hired an outside company to come and clean the A/C units. The DOM stated he was told they were coming, but they had not been there yet. The DOM stated he reviews work orders in the morning. The DOM said, I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 6 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some review them. I clean one unit here and there as I go. I am supposed to fix everything. I am one person. The DOM stated he was responsible for maintaining the vents in the kitchen. The DOM stated he was responsible for all repairs and cleaning in the entire facility. The DOM stated he was notified of dirty vents in the kitchen and laundry, and he has not gotten to them. The DOM stated the A/C in room [ROOM NUMBER] was still frozen and he had used a shop vac and sucked water out. The DOM stated he had asked housekeeping to keep mopping the water up. Review of a maintenance request dated 03/08/22 showed the DOM was notified the A/C was not working in room [ROOM NUMBER] and that a replacement was made. Maintenance requests dated 05/03/22 and 06/13/22 showed documented concerns with the A/C leaking. Completed work notes showed residents were educated. There was no documented evidence of training provided to staff related to adjusting the temperature in the room. Based on observations, interviews, record review, and review of policies and procedures the facility failed to provide a safe, clean, comfortable, and homelike environment by not ensuring: 1. cleanliness of 10 resident rooms, (104, 116, 126, 130, 131, 201, 214, 216, 226, 231) were free from dried food, spilled liquids on the floors, buildup of dust, dirt, and debris found under resident beds, broken furniture, 2. air conditioning units were free from bio-growth, dust and debris or leaking water for seven resident rooms (#106, #108 #110 #114, #231, #221, #220), 3. five ceiling vents in the kitchen were free from bio growth dust and debris, 4. two residents (#58 and #33) and in addition one resident room (#227) had sufficient clean bedding or linen. The failed to provide a safe, clean, comfortable, and homelike environment affected two wings (East and West) of two wings for four of four days of survey. Findings included: 1. On 06/27/2022 at 10:30 a.m. the following observations of resident rooms #104, #116, #126, #130, #131, #201, #214, #216, and #226 revealed: * #104 - dust and debris under the resident's bed (B), * #116 - the floor had dark brown in color stains and debris under the resident's bed (A), * #126 - dust and food particles were under the resident's bed and at side of the bed (A), * #130 - dust and debris under the resident's bed (B) and behind bedside table, * #131 - white tissues and debris alongside of the resident's bed (A) next to the wall, * #201 - dust and debris under the resident's bed (B), yellow in color stain on the floor in front of bed, * #214 (A & B)- dirt and dust under the resident's bed, brown substance on the floor next too and under the bed appeared dried and smeared, also a pale orange in color puddle of liquid dried, but also appeared to have a wet look, * #216 - empty cup and dirt under the resident's bed (A ), * #226, food particles on the floor next to and under the resident's bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 7 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 06/27/2022 starting at 10:30 a.m. interviews with residents who resided in rooms [ROOM NUMBERS] stated their rooms are not kept clean or cleaned on a routine basis. The garbage is not emptied, and bathrooms are dirty and they have seen ants, little lizards, and roaches in their rooms and reported the pests to the nursing staff. On 06/27/2022 at 4:05 p.m. an interview was conducted with the Director of Maintenance (DOM). He stated that he will speak to and follow-up with the housekeeping department to make sure the housekeeping staff are cleaning the rooms more accurately and remove all garbage and food from the rooms. On 06/28/2022 at 9:45 a.m. an additional tour of resident rooms #104, #116, #126, #130, #131, #201, #214, #216, and #226 revealed: * #104 - dust still under the resident's bed, * #116 - stain still under the bed, * #126 - dust still under the bed, * #130 - dust still under the bed, * #131 - debris still under the bed, * #201 - stain still in front of the bed, * #214 (A & B)- dirt and dust under the resident's bed, brown substance on the floor next too and under the bed appeared dried and smeared, also a pale orange in color puddle of liquid dried, but also appeared to have a wet look, * #216 - room was not cleaned, observed empty cup and dirt still there, * #226 - floor was still dirty and not mopped. On 06/28/2022 at 10:59 a.m. a phone interview was conducted with a family member of Resident #302 who stated the facility was dirty and unsanitary. The family member stated (Resident 302's) room had an oversized hole in the wall, there was trash on the floor and live roaches were observed in the room. The family member stated the bathroom was disgusting, smelled like urine and it was all over the floor. The family member stated there was feces on the wall. The family member stated the bathroom had no soap in the dispenser or paper towels in the holder; the dresser was very dirty and broken. The family member spoke with the nurse (could not remember his name) regarding the condition of the room and told him that she was signing (Resident #302) out and taking her home. On 06/28/2022 at 4:50 p.m. an interview with the Nursing Home Administrator (NHA) was conducted related to the NHA's expectation of cleaning the residents' rooms. The NHA stated, yes, it is obvious that we have issues with accomplishing those tasks, and we could do a lot better; but the company that is contracted for housekeeping cannot find sufficient help to staff the building. The NHA stated the housekeeping policies and procedures are those of the management company not of the facility company. The NHA stated he has addressed the concern with their management. On 06/30/2022 at 8:04 a.m. an interview was conducted with Staff A, Housekeeping Manager and Staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 8 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some B, Housekeeping Area Manager. Staff A and B both stated they are short staffed and are doing the best job they can. Staff A stated she is well aware of how the building is looking and they are trying to keep on top of things. The employees are working hard and extra days to get it completed but just can't get to all of it at once. She stated the staff, as far as she knows is properly trained but has not been able to do a proper training with the current staff, since arriving at the facility. Staff A confirmed they are to clean every room during a shift and stated, we do try, but I know that we do miss rooms and then they fall behind. On 06/30/2022 at 10:00 a.m. a follow-up interview with the NHA was conducted. He stated that yes, the building needs a lot more attention, although it is cleaner than it has been, and the staff are trying and working to get it completed. He also stated he has come in at night and on weekends to assist the staff with routine cleaning, washing, and waxing of floors and has done resident room deep cleans. 06/30/2022 at 2:45 p.m. an interview with the District Manager for the housekeeping contract management company apologized for the way the building was presented during survey. He stated they are short staffed and doing the best with what they have. A review of the housekeeping contract management company document agreement with the facility revealed under Article II Responsibilities and Duties of Housekeeping Company: (2.1) Laundry and Housekeeping Responsibilities (a) Housekeeping Company will establish laundry and housekeeping policies, philosophies and objectives to provide the Client with laundry and housekeeping services that meet all of the Clients legal, regulatory and professional obligations with respect to the services being performed by Housekeeping Company hereunder for Housekeeping Company 's scope of work. (b) Housekeeping Company will, during the term of this agreement, provide laundry and housekeeping services in a manner reasonably consistent with the policies and procedures established pursuant to section 2.1(a) and all legal, regulatory and professional requirements governing their scope of work. Such laundry services shall also include customary services for personal clothing for resident of client. (c) All laundry and housekeeping services shall be provided by employees of Housekeeping Company and will provide on site at Clients facility. Housekeeping Company will also provide local supervisor as well as a district manager to oversee operations and ensure quality control and compliance with the obligations under this Agreement. (d) If client's agents identify any violation of this agreement, including performance that may subject Client to citations or tags by the regulatory agencies, Housekeeping Company shall correct the issue to the reasonable satisfaction of Client. (Photographic Evidence Obtained) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 9 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to implement interventions identified in the comprehensive person-centered care plan for two residents (#35 and #296) related to falls and the refusal of care of a total sample of forty-seven residents. Findings included: 1. A review of the admission Record revealed Resident #35 was admitted on [DATE]. The admission Record included diagnoses not limited to history of falls, Type 2 Diabetes Mellitus without complications, and unspecified bipolar disorder. A review of the Quarterly Minimum Data Set (MDS), dated [DATE], identified the resident's Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating an intact cognition. During an interview with Resident #35, on 6/27/22 at 3:34 p.m., the resident's bed was hip-high. The resident reported going to the hospital due to sliding out of bed. The resident has the bed controller in reach and can move the bed up and down. Resident #35 reported not knowing how high the bed was and did not want the bed that high, and thought the bed was in a low position. On 6/28/22 at 8:43 a.m., an observation was conducted with Staff C, Licensed Practical Nurse (LPN) of Resident #35. The resident's bed was in a hip-high position, near the height of the room's windowsill. Staff C did not advise the resident in lowering the position of the bed. An observation on 6/29/22 at 12:00 p.m., identified Resident #35's bed was in a hip-high position. The resident reported not having a bed height preference. A review of Resident #35's Order Summary Report as of 6/30/22 indicated a physician order that started on 6/3/22 for a low bed every shift for fall prevention. The care plan for Resident #35 identified a focus as the resident had an actual fall 5/17/22 and the intervention initiated on 5/18/22 indicated the resident should have the Bed in low position. During an interview and observation on 6/29/22 at 3:25 p.m. with Staff G, Unit Manager/Registered Nurse (UM/RN), Resident #35's bed was observed as being in a higher than hip height. The UM stated the resident was able to adjust the height of the bed and the resident was not a fall risk but did have a fall in May (2022). Staff G stated if a physician order and the care plan indicated the resident have a low bed, then the care plan intervention was not appropriate and should be changed. Staff G indicated Resident #35 fell out of bed due to reaching for items on her over-bed table. 2. A review of the admission Record showed Resident #296 was admitted on [DATE]. The admission Record included diagnoses not limited to age-related osteoporosis without current pathological fracture (8/10/20), Parkinson's disease, unspecified Alzheimer's disease, and paranoid schizophrenia. A review of the Annual Minimum Data Set (MDS), dated [DATE], identified a BIMS score of 6 out of 15, indicating a severe cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 10 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The medical record of the resident contained a Physician's Evaluations of Resident's Capacity To Make Health Care Decisions Or Provide Informed Consent, signed by an Attending and Consulting Physician on 5/9/16 an indicated the resident was incapacitated. A care plan for Resident #296, initiated on 8/20/20 and cancelled on 1/3/22, indicated the resident was resistive to care: refusing meds (medications), labs, care, turning and repositioning, shower, is verbally and physically abusive with staff providing care, and confabulation of stories. The intervention, dated 12/2/20, identified if resident was refusing care/shower staff should contact family member, who was also designated as the resident's Health Care Proxy (HCP). A progress note, dated 12/22/21 at 3:45 p.m., read Resident #296 had mobility issues when out of bed and stated, hip hurts. The note identified a mobile x-ray was ordered for mobility issues. A progress note, dated 12/23/21 at 11:53 a.m., indicated Resident #296 refused xray and a stat x-ray was reordered due to complaints of pain and the resident reported a fall. The progress notes between 12/22/21 at 3:45 p.m. and 12/23/21 at 11:53 a.m., did not identify the family member was notified of either x-ray, the reported fall, or that staff had attempted to contact the family member after Resident #296 had refused the first attempted x-ray as the care plan instructed staff. A Change in Condition (SBAR [Situation-Background-Assessment-Recommendation]), effective 12/23/21 at 3:45 p.m., indicated X-ray results were positive for acute fracture of right femur and complaints of pain which started on 12/22/21. The SBAR indicated the HCP was notified of the situation at 3:45 p.m. on 12/23/21. The policy titled, Plans of Care, effective 11/30/14 and revised 9/25/17, indicated an individualized person-centered plan of care will be established by the interdisciplinary (IDT) with the resident and/or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements. The policy identified the following: - Review, update and/or revise the comprehensive plan of care based on changing goals, preferences, and needs of the resident. The interdisciplinary team shall ensure the plan of care addresses any resident needs and that the plan is oriented toward attaining or maintaining the highest practicable physical, mental, and psychosocial well-being. - The Individualized Person Centered plan of care may include but is not limited to the following: - Individualized interventions that honor the resident's preferences and promote achievement of the resident's goals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 11 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. An observation was made on 6/27/22 at 4:32 p.m., of Resident #12's nebulizer mask with attached tubing lying on top of the bedside dresser and a nasal cannula on the floor in front of the resident. The mask was not stored in a plastic bag. The resident stated that staff put liquid in the machine (nebulizer) and then she takes it off, and that she just dropped the cannula. Residents Affected - Few On 6/29/22 at 3:22 p.m., an observation was made of Resident #12's room with Staff G, Unit Manager/Registered Nurse (UM/RN). The resident's nebulizer mask was lying on top of the bedside dresser. The staff member confirmed the nebulizer tubing and mask was not dated and no storage bag was available. The resident's nasal cannula was lying across the bed. A plastic bag was hanging from the resident's oxygen concentrator. A review of the admission Record revealed Resident #12 was admitted on [DATE]. The admission Record included diagnoses not limited to unspecified chronic obstructive pulmonary disease and type 2 Diabetes Mellitus without complications. The Order Summary Report, active as of 6/29/22, identified the following physician order: - Ipratropium-Albuterol Solution 0.5-2.5 milligram/3 milliliter (mg/mL), one dose inhale orally three times a day (TID) related to unspecified Chronic obstructive Pulmonary Disease (COPD). The Order Summary Report for June 2022 for Resident #12 did not include an order for the oxygen or to change oxygen equipment. A review of the resident's June 2022 Medication Administration Record (MAR) did not include an order for oxygen 3. An observation was made on 6/27/22 at 9:53 a.m. of Resident #78's continuous positive airway pressure (CPAP) mask lying on the over-bed table on top of other personal items. The mask was not stored in a protective bag. An observation was made on 6/29/22 at 3:23 p.m., with Staff G of Resident #78's CPAP mask lying on top of the over-bed table not protected by a bag. The staff member stated no the mask was not stored appropriately. Staff G stated, on 6/29/22 at 4:15 p.m., Resident #78 was able to put on and remove the CPAP mask independently, however staff should be putting it in a bag after cleaning it and was unsure if staff were washing the mask after use. A review of Resident #78's Quarterly Minimum Data Set (MDS), dated [DATE], identified diagnoses that included respiratory failure and asthma, COPD or chronic lung disease. According to the admission Comprehensive Assessment, dated 10/31/21, Resident #78 received oxygen therapy as a resident. During an interview an observation, on 6/29/22 at 3:25 p.m., Staff G, UM/RN stated oxygen equipment (nebulizer equipment, nasal cannulas, CPAP mask) should be stored in a plastic bag when not in use and changed weekly. The staff member identified physician orders should include CPAP cleansing orders. She stated if the nurse sees oxygen equipment stored out of a bag and not in use they should be putting it back into the bag and that it was done for infection control. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 12 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The COVID-19 Pandemic Plan, dated 3/2/20 and revised 3/11/22, identified Oxygen tubing will be changed when contaminated or when it malfunctions per CDC (Centers for Disease Control and Prevention) guidance. Based on observations, interviews, and record review the facility failed to ensure respiratory care and services were provided consistent with professional standards of practice for three residents (#89, #12 and #78) related to: 1. not obtaining a physician's order for use of oxygen for one Resident #89, and 2. not maintaining respiratory equipment in a sanitary manner for two residents (#12 and #78) out of five residents sampled for respiratory care. Findings included: 1. An interview was conducted with Resident #89's family member on 06/27/22 at 10:50 a.m. stating (Resident #89) has had breathing issues. He noted she was supposed to get an appointment to see her pulmonary doctor. He indicated, usually the facility is good at updating him. An observation was made on 06/28/22 at 8:55 a.m. of Resident #89 sleeping comfortably. No signs of shortness of breath or gasping were noted. Observed oxygen tubing placed via nasal cannula and free of kinks. An observation was made on 06/28/22 at 10:37 a.m. of Resident #89 with oxygen tubing tied on top of her forehead. Staff E, Registered Nurse (RN), revealed Resident #89 has some shortness of breath and is putting her on oxygen. Staff E took Resident #89's blood pressure. Staff E noted Resident #89 never ties the tubing around her head. Staff E opened a new bag of oxygen tubing and place the tubing on her face. Resident #89 stated she has a pulmonary appointment tomorrow. Observed Staff E direct Resident #89 on breathing in and out and monitor blood pressure. An observation was made on 06/28/22 at 12:43 p.m. of Resident #89 eating her lunch. Observed the resident remove her oxygen tubing and unsteadily get up and move towards the dresser. Resident #89 stated she thinks she is fine and does not need assistance. An interview was conducted with Resident #89's family member on 06/28/22 at 12:53 p.m. stating (Resident #89) has an appointment to see the pulmonary doctor on Friday at 8:30 a.m. He indicated the facility alerted him of the appointment yesterday before he left the facility. An interview was conducted with Staff F, Licensed Practical Nurse (LPN), on 06/29/22 at 8:13 a.m. stating Resident #89 has a concentrator and should have continuous oxygen but will take it on and off. She revealed Resident #89 would need an order to give continuous oxygen. Staff F indicated Resident #89 needs it because her O2 (oxygen) levels drop and changes her mentation. Staff F was observed to scroll up and down Resident 89's chart looking for the physician's order. She confirmed a continuous oxygen physician's order for Resident #89 is not in place and will call the doctor to add it. An observation was made on 06/29/22 at 12:08 p.m. of Resident #89 sleeping comfortably in bed with oxygen in place via nasal cannula. Review of Resident #89 admission Record revealed an admission date of 06/03/22 with a diagnosis of chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS), dated [DATE], revealed in Section C - Cognitive Patterns (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 13 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Resident #89's Brief Interview for Mental Status score was a 13 of 15, indicating, cognitively intact. Section J - Health Conditions revealed Resident #89 has shortness of breath with exertion, sitting at rest, and lying flat. Section O - Special Treatments, Procedures, and Programs revealed Resident #89 is receiving oxygen treatment. Residents Affected - Few Review of Resident #89's Order Summary Report for June 2022 revealed physician's orders as follows: Pulmonary Consult for hypercapnia and CO2 (carbon dioxide) for one time a day for Dx (diagnosis), order and start date of 06/23/22, Appointment: Pulmonary appointment with [Doctor] on July 1st at 8:30 a.m. located at [address of doctor office] every day and night shift for pulmonary consult for 1 Day, order date of 06/23/22 and start date 7/1/22, Diagnostic home sleep study post respiratory evaluation, order date 6/23/22, Respiratory consult for eval (evaluation) for possible cpap use, order date 6/23/22, Combivent Respimat Aerosol Solution 20-100 MCG/ACT (micrograms/ actuation) (Ipratropium-Albuterol)1 puff inhale orally QID (four times daily) for COPD, order and start date 6/03/22. The Order Summary Report for Resident #89 was silent of physician orders for use of continuous oxygen and to change or maintain oxygen equipment. Review of the care plan revealed a focus area, dated 06/03/22, as (Resident #89) has COPD. The Goal, dated 06/03/22, revealed the resident will be free of s/sx (signs/symptoms) of respiratory infections and will display optimal breathing patterns daily. The Interventions included: give aerosol or bronchodilators as ordered and to monitor or document any side effects (06/03/22), monitor for difficulty breathing on exertion (06/03/22), oxygen as needed/ordered (06/03/22). Another care plan revealed a focus area, dated 6/29/22, as (Resident #89) does not cooperate with care r/t (related to) keeping oxygen on, taking meds (medications) and accepting care assist from staff. The Goal revealed the resident will cooperate with care through the next review date. Review of a progress note, dated 06/23/22, revealed Resident #89 is refusing to wear oxygen and was frequently educated and reminded the resident how important it is to leave oxygen on/in her nose .Resident refused care. Review of a progress notes dated 06/06/22, 06/08/22, 06/09/22, 06/10/22, 06/13/22, 06/14/22, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 14 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 06/16/22 .revealed Resident #89 was using Oxygen via nasal cannula via 2 liters. Level of Harm - Minimal harm or potential for actual harm Review of the O2 Sats (saturation) Summary revealed for dates: 06/03/22, 06/07/22, 06/08/22, 06/10/22, 06/13/22, 06/14/22, 06/20/22, 06/24/22, 06/25/22, 06/26/22, 06/27/22, 06/28/22, 06/29/22, and 06/30/22 Resident #89 was receiving Oxygen via Nasal Cannula. Residents Affected - Few Review of the policies and procedures titled, Oxygen Therapy, dated 11/30/14, revealed under Policy: In the event that a resident requires the use of oxygen to manage a medical condition, The Company will offer assistance as ordered by the resident's physician . It was revealed under the Procedure: 1. The nurse will organize the oxygen therapy as ordered by the resident's physician . Review of the policies and procedures titled, Physician Orders, dated 11/30/14 and revised on 03/03/21, revealed under Policy: The center will ensure that physician orders are appropriately and timely documented in the medical record. Under Procedure: admission Orders: Information received from the referring facility or agency to be reviewed, verified with the physician, and transcribed to the electronic medical record. The attending physician will review and confirm orders. Confirmation of admission orders requires that the physician sign and date the order during, or as soon as practicable after it is provided, to maintain an accurate medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 15 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record review, the facility failed to provide pain management by not ensuring pain medications were administered in a timely manner for one resident (#4) of two residents reviewed for pain management. Residents Affected - Few Findings included: During a facility tour on 06/27/22 at 12:02 p.m., Resident #4 stated she had not received her 9:00 a.m. meds (medications). Resident #4 stated she had also asked for a PRN (as needed) med for pain. Resident #4 confirmed she did not received anything all morning and she did not know why. Resident #4 stated she first asked for her Oxycodone for pain at around 8:30 a.m. Resident #4 said, This happens quite often and sometimes they give me double a dose because they did not administer the first dose on time. This is not the first time. It is not right. Resident #4 was noted grimacing and re-stated she had requested pain meds all morning. Resident #4 stated it was frustrating not to have her medications. An immediate interview was conducted on 06/27/22 at 12:05 p.m. with Staff L, Registered Nurse/Unit Manager (RN/UM). Staff L confirmed medications scheduled at 9:00 a.m. should have been administered at the latest by 10:00 a.m. and medications due at 10:00 a.m. should be administered by 11:00 a.m. Staff L stated they have a two-hour window, an hour before, and an hour after. Staff L stated three nurses had called off and every manager was assigned to a medication cart. Staff L stated their back up plan is to utilize unit managers, which they did. Staff L stated they will have to contact the doctor because the medications were past the ordered medication time. Review of the physician orders for Resident #4, dated 06/27/22, and the Medication Administration Record (MAR) for 6/1/22 to 6/30/22 showed the following medications were scheduled at 10:00 a.m.: Gabapentin Capsule 100 MG (milligram), give 100 MG by mouth five times a day for pain. Give with 600 MG to equal 700 MG. Gabapentin tablet 600 MG Give 600 MG by mouth five times a day for pain. Give with 100 MG to equal 700 MG. The review also showed Resident #4 had the following PRN medication: Oxycodone HCI tablet 300 MG, give 1 tablet every 4 hours as needed for pain. Documentation showed the medication was administered at 12:30 p.m. On 06/27/22 at 12:19 p.m., an interview was conducted with the Assistant Director of Nursing/Infection Preventionist (ADON/IP). The ADON/IP stated she was assigned all front and East side of the facility and was assigned to Resident #4. The ADON stated she was aware she was late administering some of the medications and was doing her best to get around. The ADON stated she had just called the doctor regarding Resident #4. The ADON stated the resident should have received her medications sooner. She stated they had three nurses call off and she was administering medications by priority. On 06/27/22 at 12:30 p.m. the ADON/IP stated she had called the doctor and he had said to administer all current medications, whatever is due now. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 16 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 06/27/22 at 12:14 p.m., the facility administration [Nursing Home Administrator, (NHA), Director of Nursing (DON) and the Regional DON] was notified Resident #4 had not received her morning medications. The NHA said, The problem is three nurses had called in this morning and we could not find a replacement. The DON stated the unit managers were covering the medication carts. The DON stated it was unacceptable to have residents wait that long to receive their medications. The DON agreed it was past the administration window. The DON stated they would notify the doctor and follow -up accordingly. On 06/27/22 at 3:07 p.m., a follow -up interview was conducted with Resident #4. Resident #4 stated the doctor had her skip her Gabapentin dose, but she received her pain medication and her morning medications at 12:30 p.m. A follow -up interview was conducted on 06/30/22 at 11:20 a.m. with the DON related to late medications. The DON said, Monday was a bad day, we had too many call- off's that was why we had late meds. The DON stated they received approval to administer meds. The DON said, If someone has a 9:00 a.m. med time, administration should start at 8:00 a.m. and be done latest by 10:00 a.m. 10:00 a.m. medications should be administered by 11:00 a.m. Review of a facility policy titled, Medications - Oral Administration of, with a revision date of 08/15/2019, showed a procedure to: -Review physician's order. -Review the MAR or EMAR (electronic medication administration record) should there be any uncertainties, verify the MAR or EMAR with the physician's order sheet and seek clarification as indicated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 17 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Twenty-six medication administration opportunities were observed and six errors were identified for two residents (#100 and #83) of five residents observed. These errors constituted a 23.08% medication error rate. Residents Affected - Few Findings included: 1. On 6/28/22 at 9:03 a.m., an observation of medication administration with Staff E, Registered Nurse (RN), was conducted with Resident #100. The staff member dispensed the following medications: - Amlodipine 2.5 milligram (mg) tablet orally - Pantoprazole Delayed Release (DR) 40 mg tablet orally - Topiramate 100 mg tablet orally - Gabapentin 600 mg - 2 tablets orally - Lisinopril 40 mg tablet orally - Vitamin C 500 mg tablet orally - Vitamin D3 25 microgram (mcg)/ 1000 international unit (iu) tablet orally - Vitamin B 12 500 mcg tablet orally - Duloxetine 60 mg DR caplet orally - Oxycodone-Acetaminophen 7.5-325 mg tablet orally - Zofran 4 mg tablet orally During the dispensing of the above medication, Resident #100 informed Staff E that she did not want the intravenous Vancomycin at this time. The staff member administered the oral medication. On 6/28/22 at 11:06 a.m. Staff E reported Resident #100 was ready for the Vancomycin. An observation identified Staff E began Resident #100's intravenous Vancomycin 1 gram (gm)/200 milliliter (mL). The Vancomycin was to be delivered at 133 mL/hour. A review of Resident #100's June 2022 Medication Administration Record (MAR) identified the following physician orders: - Vitamin D3 tablet (Cholecalciferol) - Give 1 tablet by mouth one time a day for supplement, started 6/9/22. - Vancomycin Hydrochloride (HCl) Solution - Use 1 gram intravenously every 12 hours for infection for 4 weeks, started 6/9/22. Scheduled for 9 a.m. and 9 p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 18 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The review of Resident #100's physician order for Vitamin D3 identified no dosage was noted. According to the acute care facility from where the resident was admitted indicated the resident was ordered Vitamin D3 5000 iu once a day. The website Good RX (www.goodrx.com) indicated Vitamin D3 was available in 400 iu, 800 iu, 1000 iu, 2000 iu, 5000 iu, 10000 iu, and by prescription 50000 iu. A review of the Progress Notes from 6/28/22 did not indicate the physician was notified that Resident #100's Vancomycin was administered two hours after the scheduled time. 2. On 6/28/22 at 11:06 a.m., an observation of medication administration with Staff H, Licensed Practical Nurse (LPN), was conducted with Resident #83. The staff member dispensed the following medications: - Vitamin D3 25 microgram (mcg) 2 tablets (1000 iu each) orally - Calcium Carbonate 750 mg chewable 2 tablets orally - Senna 8.6 mg tablet orally - Metoprolol Succinate Extended Release (ER) 25 mg tablet orally - Alprazolam 0.25 mg tablet orally. The observation identified Staff H dispensed the Vitamin D3, Calcium Carbonate, and Senna into a single medication cup. The staff member attempted to dispense the Metoprolol tablet into the same cup, dropping it onto the medication cart. Staff H applied a glove and placed the Metoprolol tablet into the cup that contained the other tablets then removed the glove. The observation was interrupted and the staff member acknowledged the tablets were contaminated and would have to be re-dispensed. Staff H dispensed the above medications a second time and a tablet of Alprazolam into the same medication cup. The staff member gave the medication cup to Resident #83. The resident commented, when placing the first Calcium Carbonate tablet into her mouth, that the tablet was a big one. The resident swallowed all the medications without the staff member instructing that the two tablets of Calcium Carbonate were to be chewed. A review of Resident #83's June 2022 Medication Administration Record (MAR) indicated the following orders: - Vitamin D3 Tablet (Cholecalciferol) - Give 1000 unit by mouth everyday for supplement. Started 6/10/21. - Vitamin D3 Tablet 25 mcg (Cholecalciferol) - Give 2 tablet by mouth one time a day for vitamin deficiency. Start date 12/11/21. - Calcium Carbonate Tablet - Give 2 tablet by mouth everyday related to Gastro-Esophageal Reflux disease without esophagitis. Start date 6/9/21. - Senna- Docusate Sodium tablet 8.6-50 mg (Sennosides-Docusate Sodium) - Give 1 tablet by mouth everyday for constipation. Start date 6/9/21. The MAR identified that Staff H documented both Vitamin D3 orders and the tablet of Senna Docusate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 19 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Sodium was administered. Level of Harm - Minimal harm or potential for actual harm The Cleveland Clinic (https://my.clevelandclinic.org/health/drugs/20402-calcium-carbonate-chewable-tablets) instructed users of Calcium Carbonate chewable tablets to Chew it completely before swallowing. The website, Drugs.com (https://www.drugs.com/mtm/senna-s.html#:~:text=Senna%20is%20a%20laxative.,listed%20in%20this%20medication%20 described Senna S has a combination of Docusate (stool softener) and Senna (laxative) medication to treat occasional constipation. Residents Affected - Few On 6/30/22 at 2:49 p.m., the Director of Nursing stated she would expect Resident #100's Vitamin D3 order to have a dosage and confirmed the resident's Vancomycin was given outside of the allowable timeframe. She reviewed Resident #83's orders and confirmed the resident had two different Vitamin D3 orders, an asked how did the resident swallow the Calcium Carbonate tablets. The policy titled, Physician Orders, effective 11/30/12 and revised 3/3/21, indicated: The center will ensure that Physician orders are appropriately and timely documented in the medical record. The procedure required staff to review admission Orders, verify with the physician, and to be transcribed in the electronic medical record. The policy titled, Medication - Oral Administration of, effective 11/30/14 and revised 8/15/19, indicated the following: - Review the MAR or EMAR (electronic medical administration record) should there be any uncertainties verify the MAR or EMAR with the Physician's Order Sheet (POS) and seek clarification as indicated. - Compare the medication unit/dose label against the MAR or EMAR prior to returning the medication container or card to the medication cart or disposing of the empty container; and prior to supporting the resident to accept and ingesting the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 20 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, interviews and record review, the facility did not ensure medications stored an inaccessible to unauthorized staff, residents, and visitors for three residents (#40, #90 and #53) for two days (6/27/22, 6/28/22) of a four day survey. Findings included: 1. During a facility tour on 06/27/22 at 10:23 a.m., an observation was made in Resident #40's room of four tablets on the floor between two dressers. A small water glass and a medicine cup were noted on the floor next to the tablets. One tablet was large, white, an oval shaped; one table was small, round, and pink; one tablet was small, round and light orange, another tablet was dark pink and round. On 06/27/22 at 12:03 p.m., a second observation was made of the same tablets on the floor between two dressers in Resident #40's room. During the second observation, it was noted that housekeeping had already cleaned the room. On 06/27/22 at 3:15 p.m., a third observation was made of the four tablets in Resident #40's room. During this observation, an additional small, round, yellow tablet was noted by Resident #40's foot of the bed. This small yellow pill was not on the floor during previous observations. An immediate follow- up interview was conducted with Staff L, Registered Nurse (RN) Unit Manager on 06/27/22 at 3:15 p.m Staff L came to the room and made the observation. Staff L said, Oh my, that is quite a few pills. Staff L stated it looked like someone dropped all her [Resident #40] medications. Staff L put on gloves and proceeded to pick up the five tablets. Staff L stated the expectation is for residents to be supervised during medication administration. Staff L stated he would find out what the tablets were. On 06/27/22 at 3:30 p.m. an interview was conducted with Staff H, Licensed Practical Nurse (LPN), who was assigned to the unit and Staff L, RN. Staff L stated they had identified the pills and confirmed they belonged to Resident #40. Staff L identified the tablets as Pantoprazole 20 MG (milligrams), Metoprolol 50 MG, Metformin HCI ER 500mg and Losartan 50 MG. and Hydrochlorothiazide. Staff L stated the four tablets looked like they had been there a couple days earlier and they were all her 9:00 a.m. meds (medications). Staff L stated he did not know who had dropped them or why they were on the floor. Staff L stated the pill found on the floor by the foot of the bed was Pantoprazole 20 MG. Staff L stated it looked like it was dropped today. Staff L stated he would follow- up. Staff H, LPN stated [Resident #40] takes her meds in pudding and it did not make sense why the pills were on the floor. Staff H stated they could not speculate how it happened. Staff L, RN said, Either way there is no excuse. Residents should be supervised during med administration. 2. During a tour of Resident #90's room on 06/27/22 at 11:00 a.m. an observation was made of a medium size dark pink oval shaped tablet on the floor. Resident #90 stated he did not know how long it had been on the floor. A second observation was made on 06/27/22 at 2:53 p.m. and the same tablet was on the floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 21 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 On 06/27/22 at 3:07 p.m., a third observation was made of the tablet on the floor in Resident #90's room. Level of Harm - Minimal harm or potential for actual harm An immediate interview was conducted with Staff L, RN on 06/27/22 at 3:07 p.m Staff L stated tablets should not be on the floor. Staff L said, The process is for the nurse to make sure they have the right meds for the right resident, have water, stay with the resident until they swallow and then document. Staff L stated he did not know why the tablet was on the floor or how long it had been there. Staff L stated he would find out what it was and dispose (of the medication) per their policy. Staff L followed up on 06/07/22 at 3:12 p.m. and stated the medication was Omeprazole and it belonged to Resident #90. Residents Affected - Few 3. During a tour of Resident 53's room on 06/28/22 at 12:50 p.m., an observation was made of a round peach colored tablet with a 5 inscribed on the top. The tablet was observed under the air conditioning unit, next to Resident #53's bed. An immediate interview was conducted with Staff L, RN who was in the room at the time on 06/28/22 at 12:50 p.m. Staff L stated he did not know what it [the tablet] was but would find out. On 06/28/22 at 2:33 p.m. Staff L followed up and stated he had reviewed all the medications for both residents in the room and the orders did not match the tablet found on the floor in the residents' room. Staff L stated it looked like a hydrochloride 5 MG but neither of the residents in this room were taking it at this time. Staff L stated it may have been there a while. An interview was conducted on 06/27/22 at 3:37 p.m. with the Director of Nursing (DON) and the Regional DON. They were notified of the medications observed on the floor. The DON stated the expectation is for residents to be supervised during med administration. The expectation is for the nurse to remain with the resident during the entire process. On 06/30/22 at 11:20 a.m., an interview was conducted with the DON related to medication on the floor. The DON stated that residents should be monitored during medication administration. The DON said, There should be no loose tablets on the floors. It is a safety hazard. Review of a facility policy titled, Medication and Medication Supply Storage and Disposal, dated 11/30/2014, showed central storage of medications is required for prescription, prescribed over the counter medications and [complimentary] and alternative medications. Medications will be kept locked in a locked area, in their original labeled container and may not be removed more than 2 hours prior to the scheduled administration. Meds will be kept in a medication cart that locks and keys only accessible to the licensed personnel distributing medications. Review of a facility policy titled, Medications - Oral Administration Of, with a revision date of 08/15/2019, showed a procedure to: -Review physician's order. -Review the MAR or EMAR should there be any uncertainties, verify the MAR or EMAR with the physician's order sheet and seek clarification as indicated. -Prepare medications for one resident at a time. -Compare the medication unit/dose label against the MAR (medication administration record) prior to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 22 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 supporting the resident to accept and ingesting the medication. Level of Harm - Minimal harm or potential for actual harm -Check resident's picture / ID. -Allow residents as much water as they desire unless fluids are restricted. Residents Affected - Few -Document the administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 23 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to implement an effective Infection Control Program in response to COVID-19 as evidenced by: 1. two staff members (O, K) not doffing Personal Protective Equipment (PPE) and not wearing PPE appropriately in two of two COVID positive rooms (room [ROOM NUMBER] and room [ROOM NUMBER]); 2. not providing clean and sanitary water cups on a daily basis for three residents (#33, #35 and #407) and in two resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]); 3. one staff member (U) not performing hand hygiene during the passing of food trays on one unit (West) of two units; and 4. not maintaining a clean environment in the laundry area used to process facility linen and the residents' personal items with the potential to affect a census of 97 residents. Residents Affected - Some Findings included: 1. On 6/27/22 at 12:15 p.m., an observation was made of Staff O, Restorative Aide, standing in the hallway outside of room [ROOM NUMBER], where a COVID-19 positive resident (#405) was residing. Staff O was observed doffing a blue isolation gown, placed it in an opaque trash bag and then began to walk toward the end of the hallway to the nursing station without performing hand hygiene. Staff O stated the gown should have been removed prior to exiting the room and hand hygiene was going to be done in the dirty utility room. A review of the Centers for Disease Control and Prevention (CDC) infection control guidelines for isolation titled, 2007 Guideline for Isolation Precautions Preventing Transmission of Infectious Agents in Healthcare Settings, last updated May 2022 instructed: Remove gown and perform hand hygiene before leaving the patient's environment. (accessed at https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html) On 6/28/22 at 10:02 a.m., an observation was made of Staff K, Housekeeper, standing near the first bed in room [ROOM NUMBER] sweeping. Posted on the door of room [ROOM NUMBER] was a sign that identified visitors, including staff, were to observe Droplet Precautions. Both residents in room [ROOM NUMBER] were COVID-19 positive. Staff K was observed in the room without wearing a gown, eye protection, or gloves. When leaving the room, the staff member placed the cleaning equipment on the housekeeping cart parked outside of the room and reported being educated on the use of PPE. Staff K acknowledged PPE should have been worn in room [ROOM NUMBER]. An interview was conducted at 10:08 a.m. on 6/28/22, with the Housekeeping District Manager who stated yes, the contracted staff had been educated on the use of PPE and should be wearing appropriate PPE while in a COVID positive room. Staff K, Housekeeper was observed, on 6/28/22 at 10:10 a.m., in a different hallway (Rooms 219 - 232). Staff K reported being re-educated on the use of PPE from the manager. The staff member stated he received no other advisements in response to contamination from being exposed to COVID positive residents. The Nursing Home Administrator reported on 6/28/22 at 10:18 a.m., the housekeeper (Staff K) who was observed in the COVID positive room was being sent home. A sign posted on the doors of room [ROOM NUMBER] and 218 instructed everyone to clean their hands (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 24 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some before entering and when leaving the room, make sure their eyes, nose, and mouth are fully covered before room entry, or remove face protection before room exit. (Photographic Evidence Obtained.) The policy titled, Isolation - Categories of Transmission-Based Precautions, revised October 2018, indicated: Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. The Droplet Precautions section of the policy indicated masks would be worn, gloves, gown, and goggles should be worn if there is risk of spraying respiratory secretions. 2. On 6/27/22 at 10:05 a.m., an observation indicated a foam cup sitting on the over-bed table of the second bed in room [ROOM NUMBER], the cup was dated 6/24. On Monday, 6/27/22 at 10:37 a.m., an observation identified a foam cup sitting on the over-bed table for the first bed of room [ROOM NUMBER], written on the cup was Friday. During the observation of room [ROOM NUMBER], the second bed was observed with a foam cup on the over-bed table with Jun 24, written on it. (Photographic Evidence Obtained). An observation was conducted on 6/27/22 at 3:29 p.m. of Resident #35's two drinking cups. One of the foam cups was dated 6/24. Staff V, Certified Nursing Assistant (CNA), confirmed the cups were from three days ago. On 6/28/22 at 2:17p.m., Resident #33 stated the night shift was supposed to change the water cups every night and they did last night but prior to that it was a couple of days, and before that the Resident's cup was dated 6/3, 21 days, it was disgusting. The resident reported the cup had backwash in it, the straws were dirty, and knew stuff was growing in it. A review of the admission Record revealed, Resident #33 was admitted on [DATE] and a review of the Quarterly Comprehensive Assessment completed on 4/21/22, the Resident's Brief Interview for Mental Status (BIMS) score was 15 out of 15, indicating the intact cognition. 3. An observation was conducted on 6/27/22 at 12:37 p.m., of one staff member passing lunch trays to the residents. The observation identified Staff U, CNA turn off the light in room [ROOM NUMBER], deliver a lunch tray to room [ROOM NUMBER] B-bed, and returned to the lunch cart and took another tray out and delivered it to the A-bed of room [ROOM NUMBER]. Staff U served coffee to the resident in room [ROOM NUMBER] B-bed, removed a tray from the lunch cart and delivered it to room [ROOM NUMBER] B-bed, took another tray to A-bed in room [ROOM NUMBER], removed a mechanical lift from room [ROOM NUMBER] then removed a tray from the lunch cart and placed it in room [ROOM NUMBER]. During this observation, that began at 12:37 p.m. on 6/27/22, Staff U, CNA did not perform hand hygiene. Staff U stated, on 6/27/22 at 12:55 p.m., yes, sanitizing and/or washing hands between residents while passing meal trays was supposed to be done and confirmed hand hygiene was not done. Staff U said, I forgot. 4. An observation on 6/28/22 at 2:50 p.m. was conducted with Staff M, Laundry Aide, of the laundry processing area. The staff member stated the shift worked was normally 2:30 p.m. - 9:30 p.m. but she often worked a double. Staff M stated two of the seven days a week that she didn't work the Housekeeping Manager did the laundry. The staff member stated she hadn't gotten a chance to clean the laundry room. The observation identified the outer casing of two of two washing machines were dusty, a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 25 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm matted substance was hanging from the air vent above and in front of the second washing machine, the air exchange filters on both washing machines were dusty, the blinds behind the washing machines had dust attached to them, and the water drain behind the washing machines had a tan-colored substance attached to the floor and walls and contained trash, which was also covered with the tan-colored substance. The laundry area processed both facility linens and resident personal items. Residents Affected - Some On 6/30/22 at 3:35 p.m., the Maintenance Director reported he fixes and repairs the laundry equipment and was not given a policy for cleaning the equipment. He stated in all his other buildings housekeeping was supposed to clean the areas. If the water trap behind the washing machine becomes clogged, then they put in a work order for him to unclog it. During an interview on 6/30/22 starting at 1:55 p.m., the Infection Preventionist (IP) reported staff are trained in PPE use during the town hall meeting and return demonstration was not done. The facility just asks staff to tell them how it's done. If a break in infection control is observed the IP reported education was done at that time. She stated housekeeping was expected to adhere to transmission-based precautions. The IP stated the PPE requirement in COVID positive rooms were gowns, gloves, goggles/face shields, and a N95 mask and that staff were to doff PPE prior to leaving a COVID positive room. During this interview an observation was conducted with the IP of the laundry area. Staff M, Laundry Aide was folding clean laundry during the observation. The previous findings of the laundry room remain unchanged (dusty washers, dusty blinds, and dirty water drain) and the IP stated dust could fall into the clean laundry and the water drain/trap in the laundry room should be cleaned. The observation of the foam water cups were described to the IP, and she stated the cups should be changed daily. The policy titled, COVID-19 - Pandemic Plan, dated 3/2/20 and revised 3/11/22, identified COVID-19 as a respiratory illness thought to be spread mainly from person to person, between people who come in close contact to one another (about 6 feet). The plan indicated the following: - The facility should initiate transmission-based precautions per CDC including PPE - N95 or higher respirator, eye protection, gown, and gloves for a resident with suspected COVID-19. - Staff will be trained on the facility Pandemic COVID-19 plan and related policies and procedures - Staff will be re-trained in Hand Hygiene and proper use of PPE including competency . - Cleaning and disinfection for pandemic COVID-19 follows the general principles used daily in health care settings, per CDC guidance. On 06/27/2022 at 10:15 a.m. an observation of two resident rooms (room [ROOM NUMBER] Bed A, and room [ROOM NUMBER] Bed A) revealed white foam cups with water dated June 24th on the residents' bedside tables. In addition, a white foam cup with water dated June 24th was observed in Resident #407's room and she stated the water cups are never filled or outdated. (Photographic Evidence Obtained) The policy titled, COVID-19 - Pandemic Plan, dated 3/2/20 and revised 3/11/22, identified COVID-19 as a respiratory illness thought to be spread mainly from person to person, between people who come in close contact to one another (about 6 feet). The plan indicated the following: - The facility should initiate transmission based precautions per CDC including PPE - N95 or higher respirator, eye protection, gown, and gloves for a resident with suspected COVID-19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 26 of 27 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105549 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/30/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Aviata at the Harbor 1410 Dr Martin Luther King Jr St N Safety Harbor, FL 34695 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 - Staff will be trained on the facility Pandemic COVID-19 plan and related policies and procedures Level of Harm - Minimal harm or potential for actual harm - Staff will be re-trained in Hand Hygiene and proper use of PPE including competency . Residents Affected - Some - Cleaning and disinfection for pandemic COVID-19 follows the general principles used daily in health care settings, per CDC guidance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105549 If continuation sheet Page 27 of 27